Sheila Augustine and David TemperleyLennard Funk, John Haines, Ian Trail, Mike Walton, Puneet Monga

Filling spot films

Subcoracoid

Axillary recess

Biceps sheath

Rupture of subcoracoid bursa

Introduction

! We have used hydrodilatation as a treatment for frozen shoulder for several years. We have been monitoring our results informally; this is the first formal audit of the procedure in WWL.

Presentation

! We will present! - information on frozen shoulder! - how we undertake hydrodilatation! - information on hydrodilatation from the literature! - how the study was undertaken ! - results! - summary and recommendations.

Patient selection and indications for HD WWL

! Most patients with stiff shoulder are offered HD! Almost all with FS ! Occasional patient with stiff shoulder + other Dx! Most would go on to capsular release if HD not

available ! However threshold for HD lower than surgery! Occasionally surgery first; e.g. DM with very stiff

shoulder or patient with good experience of surgery for other side or needle phobic

! Contra-indications- infection! Special precautions- anticoagulation.! Consent! Patient supine, turned towards affected

shoulder! Arm externally rotated

! identify GH joint ! (upper/ medial humerus) ! Inject local anaesthetic.! Needle directed vertically into joint.! Injection of Omnipaque 120mg/ml- confirm position! Inject Depomedrone 2ml/80mg. Local 8ml.! Return to contrast injection

! Continue injection until! …capsular rupture! …injection limited by pain! …50-55ml injected (is this frozen shoulder!)! Procedure takes 15 minutes! Patient waits in department for 10-15mins! Not to drive home, but do not restrict activities

for too long! Physiotherapy within 1 week.

Complications

! Pain- immediate due to distension. Ceases with capsular rupture or subsides in 5-15 minutes

! Pain ongoing as with any joint injection- 1-2 days, can take pain killers or anti inflammatories prn

! Infection- rate unknown- estimate vary from 1:1000 to 1:50,000

! Allergy especially to contrast.! Corticosteroid effect. 80mg Depomedrone/

methylprednisolone= 400mg hydrocortisone or 100 mg prednisolone. Warn Diabetics!

! Fluid should be injected to achieve capsular rupture if possible!

! Steroid and local anaesthetic injection should be used.!

! Diabetic patients respond less well.

! Improvement can occur immediately or take 1-2 weeks. Full improvement often requires time and physiotherapy !

! Improvement is as likely to occur in any phase of the disease, and with any severity.!

! Multiple injections can be used, but not necessary routinely

! Lots of relatively small observational studies, few controlled trials!

! Non- controlled studies indicate ‘good’ outcome of 67-94%.

! Typically 70% show significant improvement in movement and up to 90% improvement in pain.

! Controlled studies: -!

! The most quoted study shows no benefit over steroid injection only

! Other studies show HD better than steroid only and MUA

! Small studies with flawed technique.

Aims of Audit

! To assess whether Hydrodilatation is effective in the treatment of Frozen Shoulder

! Is it equally effective in all groups of patients?! Can we predict whether it will work at the time of the

procedure?! To assess how quickly patients respond- can response

be predicted at one week?! To review side effects.

Study technique- data

! 116 patients who had HD during 2010 and 2011 (118 shoulders, 119 procedures)

! Information from EPR, CRIS and PACS.! Either day lists assessed, and hydrodilatation

identified or patients followed prospectively.! INFORMATION GATHERED! PAS No, age, sex, date of H,

Study Technique- data

! Co- morbidity (diabetes and others)! Length of Symptoms! Technique- Volume injected, rupture?,

complications.! 25 patients were contacted at 1 week! Physiotherapy?! Length of follow up! Outcome: Response (pain, movement)! Outcome: Usually discharge or surgery.

Outcome/ Response! Primary outcome- surgery or discharge! Special attention if patient unfit for surgery.! Secondary outcome- pain and movement

response ‘semi-quantitative’! Standard scores for pain relief or function not

used ! e.g. SPADI, Shoulder Disability Questionnaire (SDQ-UK) and

Oxford Shoulder Score (OSS) (Generally not available)

Comparison made for different groups-! 1. Male/ Female ! 2. Age groups. ! 3. Healthy/DM/other co-morbidity ! 4. Idiopathic vs Traumatic! 5. Early rupture/ standard/ no rupture. ! 6. Consultant/ Registrar ! 7. Response at 1 week vs. final response. ! 8. Length of symptoms vs. response

Scoring of ResponseExcellent- no or minimal pain, can do all activities

without pain. Full or nearly full movement= 4 Good- Some pain and reduced movement, but can do

activities of normal daily living without restriction= 3 Fair/ Partial- Significant relief, but still some pain and

reduced movement on normal activities= 2 !

Little/ Poor- Some improvement, but still significant pain and reduced movement= 1

None= 0 Worse= -2

Patient Details

! 118 Shoulders, 116 Patients, 119 procedures!

! Indication: All frozen shoulder except 1 (OA) !

! All cases: 56 Male 62 Female (47%M:53%F)! Spontaneous FS 11 Male 15 Female (42%M:58%F)!

! Age 26-77, Mean 53

Patient age groupings

Age groups

TECHNIQUE

! 35ml injected (mean)!

! All received 80mg Depomedrone, IA LA, contrast, saline and post op physio except: !

! 1 patient- no record of LA, ! 2-patients- no record of physiotherapy

Analysis of Data

! Time from procedure to audit- 10-21 months.

! Referrers Orthopaedic 96% Rheumatology 4%

! Co-morbidity (medical)! DM 20! Others 10! Asthma, cardiac, warfarin, CRF, depression, CVD, PVD,

CML, breast ca, MS, RA! ‘DNA’

10- no record of FU, 108 Followed up

Duration of symptoms (Months)- 32 patients Mean 11 months- Median 7.5 months

Months

RESPONSE out of 108 shoulders

! Discharged without surgery, fair response or better = ‘SUCCESS’ (Special attention if not fit for surgery)!

! Needed surgery, offered surgery or awaiting surgery for frozen shoulder, or poor response in those not fit for surgery = ‘FAILURE’

RESPONSE, 108 shoulders

!

!Success 81 = 75% !

!Failure 27 = 25%

Response Scores

Score

Response- Sex and Age

Criterion Number +ve/-ve

Success %

Male 36/12 75Female 45/15 75Age <40 4/3 57Age 40’s 24/8 75Age 50’s 33/11 75Age 60+ 20/5 80

Response- co-morbidity

Criterion Number +ve/ -ve

Success %

1. Spontaneous 21/4 842. Diabetes 12/7 633. Other morbidity 6/4 604. Post trauma or surgery 12/7 635. TOTAL all cases 81/27 75

Response- Pain vs. Movement

! 58 cases!

! 44 Equal improvement (or equal lack of improvement) in pain and movement

! 11 Pain response greater! 3 Movement response greater

Response- Injected volume/ rupture. Grade of operator.

Criterion Number +ve/-ve

Success %

All rupture 65/23 74%No rupture 16/4 80%

Low volume rupture (<30ml)

6/3 67%

Consultant 66/22 75%Registrar 15/5 75%TOTAL 81/27 75%

Duration of symptoms vs response 30 patients

Success/Failure

%Success

< 7.5 months symptoms 11/4 73

> 7.5 months symptoms 11/4 73

Length of Follow Up

!Length of follow up- ! (to discharge)

!

! Mean 16 weeks! Half<3/12

Response at 1 week vs final response

N=25 FinalEx/ Good

FinalFair/ Partial

Final Poor/ None

1 week Excellent/good 12 0 11 week Fair/ Partial

3 3 21 weekPoor/None

1 0 3Few cases did well initially then badly

Complications

! Painful procedure- 2 cases recorded- recovered quickly!

! Distension of shoulder is painful, but pain goes away when capsule ruptures!

! No record of any other complications!

! Two patients died- 1 lung cancer, 1 unknown cause

Analysis of surgery

! HD> failed > surgery (N=15)! Excellent 6! Good 2! Fair 5! Poor/ Nil 2 > HD- 2nd attempt in 1>success!

! Surgery first 2 > HD- both unsuccessful

Problems with Audit

! Pain and movement measurement not objective –(however surgery or discharge is good outcome measure)!

! No control group!

! Inadequate research base!

! No accepted standard.

Summary! Hydrodilatation is a treatment for Frozen Shoulder! It is well tolerated, with no side effects apart from pain

at and soon after the time of the study. It takes about 15 minutes, and the patient goes home within 30’.

! It is associated with a ‘good’ outcome, with significant pain relief and increase in movement, precluding the need for surgery, in 75% of cases.

! It works in all groups of patients that were referred, but there is some evidence that those with secondary FS, diabetes and other co-morbidity do a little less well.

! Of those patients who do well, some recover almost immediately, while some improve slowly with physio. In most cases outcome can be predicted in 1 week.

Recommendations

!! Hydrodilatation is a treatment for frozen

shoulder. It is simple to perform, with few side effects, and is effective in ¾ of cases. It is recommended that we continue to undertake this procedure in appropriate patients.

! Present this audit to orthopaedic surgeons. Discuss referral criteria.